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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601058
Report Date: 09/15/2025
Date Signed: 09/15/2025 01:40:03 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/15/2025 01:40 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PORTOLA PLACEFACILITY NUMBER:
415601058
ADMINISTRATOR/
DIRECTOR:		ATIENZA, ARMANDFACILITY TYPE:
740
ADDRESS:445 PORTOLA DRIVETELEPHONE:
(650) 349-1755
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 4DATE:
09/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee - Armand AtienzaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 09/15/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with the licensee Armand Atienza and explained the purpose of today's visit. There are 2 caregivers in the facility and 4 residents present.

This is a two level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory. License is approved for 3 hospice residents. There are 2 hospice residents as of today's inspection visit. The second level of the facility is occupied by private renters. The access door to the second floor is secured so those renters cannot enter the facility. There is a separate entrance for that second floor unit located near the garage of the facility. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. There are no video cameras on site per the caregivers. LPA observed the facility kitchen which is in good repair. Knives are stored and locked per observation made. Perishable and non-perishable food supply in place. There is an additional refrigerator/ freezer in the garage area which carries additional food supplies for resident use. Refrigerator was observed to not meet regulatory standard in terms of cleanliness. Storage shelves and drawers were observed to be sticky and dirty, sticky, needing to be cleaned. Expired food items were observed such as sauces and milk were observed. Also it was observed the facility used of other food containers to store foods that were not intended to be in those containers that were originally for miso dressing and two containers of potato salads. Uncovered vegetables and fruits were also observed. Also in the garage is the laundry area and where the cleaning supplies are primarily stored. LPA also observed cleaning supplies locked beneath the kitchen sink.

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NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PORTOLA PLACE
FACILITY NUMBER: 415601058
VISIT DATE: 09/15/2025
NARRATIVE
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First aid kit is observed as complete with required items stored in the kitchen of the facility. Medications are observed to be locked in the kitchen in a kitchen cabinet adjacent to the refrigerator. LPA observed at least one fire extinguisher in place which are currently within operating range, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating. Inspection tag for the extinguisher indicates it was checked on 07/18/2025. Facility is not equipped with fire sprinklers. LPA also observed fire pull stations in the rear and front of the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature is measured at 121F and increasing during today's inspection. The temperature was adjusted during today's visit and is remeasured at 105F. Also observed in the bathroom is a common hand towel for resident use to use for drying of hands. LPA provided advisory notice that such should not be in place for resident use in order to prevent the spread of illness and other reasons. Linen supplies are observed as in place in a hallway closet. LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident bathrooms are observed as clean and in good worker order. Shower floor is equipped with non-skid mat for resident use. Medications and logs are observed today as current. During today's inspection LPA reviewed 4 resident files. R1 physician's report is not current to within one year and has a dementia diagnosis and there was no other evidence on file reflecting an annual medical visit being conducted but was informed that R1 did have a medical visit and will submit evidence of the visit. Staff files are reviewed and are current. Administrator certificate is observed to be current expiring 06/16/2026.

The following updated forms are requested to be submitted to CCLD by 09/22/2025:

• Copy of updated administrator certificate
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule

Report is reviewed with Armand and a copy of the report is provided. Citations are issued on this day on the attached LIC809D pages.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2025 01:40 PM - It Cannot Be Edited


Created By: Jaime Vado On 09/15/2025 at 11:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PORTOLA PLACE
FACILITY NUMBER: 415601058

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2025
Section Cited
CCR
87303(e)(2)

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87303(e)(2) Maintenance and Operation - Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This regulation has not been met as evidenced by:
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Water temperature was lowered during today's visit and was remeasured at 105F.

This citation is cleared.
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Based on facility observations made during water temperature testing, LPA found that the water temperature in the common bathroom for the facility, the water temerature was tested at 121F and increasing. This poses an immediate health and safety risk to residents in care.
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Type B
09/16/2025
Section Cited
CCR87555(23)

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87555(23) General Food Service Requirements - All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This regulation has not been met as evidenced by:
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Facility shall develop a written plan addressing how the facility will meet this regulation going forward at all times. Plan shall be submitted to the Department for review.
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Based on observations made of the facility refrigerators, LPA observed uncovered fresh foods such as cantalope, celery, onions, and other fresh vegetables were not covered appropriately. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2025 01:40 PM - It Cannot Be Edited


Created By: Jaime Vado On 09/15/2025 at 11:16 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PORTOLA PLACE
FACILITY NUMBER: 415601058

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2025
Section Cited
CCR
87465(i)

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87465(i) Incidental Medical and Dental Care - Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. This regulation has not been met as evidenced by:
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This citation was cleared during LPA's inspection visit. Medications were removed, bagged and removed from the facility for destruction.

This citation is cleared
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Based on facility ovservations made, LPA Vado found medications from a prefious resident was not destroyed properly and was being stored in the facility's refrigerator in the main kitchen. This poses an immediate health and safety risk to residents in care.
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Type B
09/16/2025
Section Cited
CCR87463(h)

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87463(h) - Reappraisals -The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This regulation has not been met as evidenced by:
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During today's visit, LPA was informed that R1 did have a visit and will provide evidence of the visit.
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Based on resident files reviewed, R1's last doctor visit notated on the physician's report is 06/03/2024, which does not meet the annual routine medial visit as outlined in this regulation. This poses an immediate heatlh and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2025 01:40 PM - It Cannot Be Edited


Created By: Jaime Vado On 09/15/2025 at 12:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PORTOLA PLACE
FACILITY NUMBER: 415601058

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2025
Section Cited
CCR
87555(b)(8)

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87555(b)(8) General Food Service Requirements - All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This regulation has not been met as evidenced by:
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Facility shall develop a written plan addressing how the facility will meet this regulation going forward at all times ensuring that food items will be inspected and disposed of appropriately and stored properly in appropriate containers.
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Based on observations made of the items in the facility refrigerator in the main kitchen, LPA found several expired items such as milk, barbecue sauce, and other items with past best use by dates. Additionally, LPA observed vegetable with mold and the reusing of containters that were for miso dressing and potato salad to store other food items hat were not originally in those containers. This poses an immediate health and safety risk to residents in care.
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Type B
09/17/2025
Section Cited
CCR87303(a)

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87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This regulation has not been met as evidenced by:
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Facility shall develop a written plan addressing how the facility will meet this regulation going forward at all times ensuring that the refrigerator will be maintained in a clean and healthful manner at all times.
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Based on obseravtions made of the refrigerator in the main kitchen, LPA found that the shelves, storage drawers, and storage areas of the refrigerator as dirty, sticky, and needed to be cleaned. This poses as a potential health and safety risk for residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2025


LIC809 (FAS) - (06/04)
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